Addressing threats to health care's core values, especially those stemming from concentration and abuse of power. Advocating for accountability, integrity, transparency, honesty and ethics in leadership and governance of health care.

Monday, March 11, 2013

A series of articles over the last few months, culminating in an investigative report by Reuters, provided the newest example of what can go wrong when corporations provide direct care to vulnerable patients. In this case, the vulnerable patients had cancer, and the corporation that provided them care was the Cancer Treatment Centers of America (CTCA). I will try to go through the case chronologically.

As Rueters reported, CTCA "was founded in 1988 by Richard J. Stephenson, who has been chairman ever since."

The Founder's Checkered Past

A Misdemeanor

As Reuters noted,

A graduate of Northwestern University Law
School, Stephenson started out as an investment banker. In 1966 he
became a trustee of Americans Building Constitutionally, an organization
that helped wealthy individuals set up not-for-profit corporations and
personal trusts to avoid paying federal income and inheritance taxes.

In
1969, a California state court found the group's top official and six
others guilty of grand theft or conspiring to commit grand theft.
Stephenson had pleaded no contest to false advertising, a misdemeanor,
and testified for the state, according to media reports at the time.

Allegations of Use of Unproven Cancer Treatments

Stephenson seemingly stayed out of trouble until 1975, but

Stephenson ventured into healthcare in 1975, when
he and partners bought Zion-Benton Hospital in Zion, Illinois, renaming
it American International Hospital. By the late 1980s, American
International was facing financial problems and its 'reputation had been
severely damaged' by local press reports about its use of unproven
cancer treatments, according to a 2004 court opinion on a successful
petition by a former CTCA president seeking an increased valuation for
his share of the company.

CTCA: No More Unsubstantiated Claims

Apparently around the time American International Hospital starting having major troubles, Stephenson branched out,

In 1988, Stephenson founded CTCA. He was
motivated, said CEO Bonner, by the difficulty he had identifying and
obtaining the best therapies for his mother after she developed bladder
cancer. She died in 1982.

By 1996, CTCA got into trouble too,

Cancer Treatment Centers of America got in
trouble with regulators in 1996, when the Federal Trade Commission
accused it of, among other things, presenting survival claims it
couldn't support. The company entered into a consent decree with the FTC
and, without admitting any of the allegations, agreed not to make
unsubstantiated outcomes claims.

"Unscientific Therapies" As far as I can tell, all was then quiet until 2012. Late that year, a Forbes columnist wrote,

Alongside standard, science-based cancer therapies, CTCA also offers
an array of questionable, unscientific therapies, which it proudly
labels as part of its 'integrative cancer treatment.' CTCA advertises many such treatments, including:

These are just a few examples. These claims, and CTCA’s marketing of the therapies involved, present a huge ethical problem.

Manipulated Survival Statistics

Then, in March 2012, the Reuters investigative reporters charged that CTCA manipulated its survival statistics to make its results look better.

CTCA reports on its website that the
percentage of its patients who are alive after six months, a year, 18
months and longer regularly tops national figures. For instance, 60
percent of its non-small-cell lung cancer patients are alive at six
months, CTCA says, compared to 38 percent nationally. And 64 percent of
its prostate cancer patients are alive at three years, versus 38 percent
nationally.

Such claims are
misleading, according to nine experts in cancer and medical statistics
whom Reuters asked to review CTCA's survival numbers and its statistical
methodology.
The experts were
unanimous that CTCA's patients are different from the patients the
company compares them to, in a way that skews their survival data. It
has relatively few elderly patients, even though cancer is a disease of
the aged. It has almost none who are uninsured or covered by Medicaid -
patients who tend to die sooner if they develop cancer and who are
comparatively numerous in national statistics.
Carolyn
Holmes, a former CTCA oncology information specialist in Tulsa,
Oklahoma, said she and others routinely tried to turn away people who 'were the wrong demographic' because they were less likely to have an
insurance policy that CTCA preferred. Holmes said she would try to 'let
those people down easy.'

Equally
significant, CTCA includes in its outcomes data only those patients 'who
received treatment at CTCA for the duration of their illness' -
patients who have the ability to travel to CTCA locations from the
get-go, without seeking local treatment first. That means excluding, for
example, those who have exhausted treatment options closer to home and
arrive at a CTCA facility with advanced disease.

Accepting
only selected patients and calculating survival outcomes from only some
of them 'is a huge bias and gives an enormous advantage to CTCA,' said
biostatistician Donald Berry of MD Anderson Cancer Center in Houston.

Furthermore,

CTCA also appears to exclude the vast majority
of its patients when it calculates survival data. In survival results
from 2004 to 2008 posted on its website, CTCA reported 61 patients with
advanced prostate cancer, 97 with advanced breast cancer, 434 with
advanced lung cancer, and 165 with advanced colon or rectal cancer.
These are the four most common solid tumors. In the same period, CTCA
treated thousands of patients at its Zion facility alone, according to
filings with state regulators.

'We
agree that some of our sample sizes' are small 'and have always stated
this as a limitation of our study,' said Xiong, the consultant to CTCA.

'I'd have some concerns about why and wonder if some cherry-picking was going on,' said Spectrum Health's Campbell.

Moreover,
while the standard reporting period for cancer survival is five years
after diagnosis, CTCA on its website doesn't go that far; for the four
most common tumors, it reports survival up to four years at most. And as
Reuters found, the company's advantage often diminishes as the
five-year mark approaches

The Founder's Checkered Present

By the way, also in the last few months, watchdog groups have asked for an investigation of CTCA's founder for possible deceptive actions that might have violated US election laws. In December, 2012, the Washington Post reported

In the weeks before the election, more than $12 million in donations was
funneled through two Tennessee corporations to the FreedomWorks super
PAC after negotiations with [CTCA Founder Richard J] Stephenson over a preelection gift of the
same size, according to three current and former employees with
knowledge of the arrangement.

Then,

Two watchdog groups last week asked the Federal Election Commission and
the Justice Department to investigate the donations from the two
Tennessee companies. The groups, Democracy 21 and the Campaign Legal
Center, say the arrangement could violate federal laws that prohibit
attempting to hide the true source of a political contribution by giving
it under another name.

Summary

In summary, there are now charges in the media that Cancer Treatment Centers of America manipulated its survival data to makes its advertised results appear better, while it also advertises unproven complementary and alternative medicine treatments as effective. In the past the company had signed a consent decree not to make (presumably any more) unsubstantiated claims. Meanwhile, the company's founder, who has a past history of a no contest plea to false advertising, and who had previously run a hospital system also charged with making unsupported survival claims, has been accused of hiding political donations.

Thus this organization, run by someone who has his own history of deception, has been found to make exaggerated and/or unsubstantiated advertising claims of several types and at different times. These claims could attract vulnerable patients who perhaps could get better care elsewhere, possibly leading to excess morbidity and even early mortality.

So Cancer Treatment Centers of America seems to be the latest reason to worry about the laissez faire US system which allows lightly regulated for-profit corporations to provide direct "care" to our most vulnerable patients. We have recently discussed how a for-profit hospital chain may have been over treating some patients and under treating others, possibly risking patients' health to increase revenues (look here); how for-profit hospice corporations by enrolling patients who do not actually have terminal illness for palliative care only could be denying potentially curative treatment to curable patients (look here); and how for-profit mental health clinics and drug treatment centers could be providing shoddy, and potentially dangerous care to boost revenues (look here and here).

We will see if the newest part of the pattern of news reports about CTCA and its founder, coupled with reports about other for-profit health care corporations that provide direct care to vulnerable patients provoke any official action. However, the pattern is substantial enough so that it should make all health care professionals and all patients reconsider whether ever to trust a for-profit hospital system, hospital, clinic or other site providing direct health care to patients.

On a policy level, as I have said before,.... In my humble opinion, before the health care bubble bursts, we need to
challenge the notion that direct health care should ever be provided, or
that medicine ought to be practiced by for-profit corporations. Before
market fundamentalism became so prominent, many states prohibited the
corporate practice of medicine, and the American Medical Association forbade the commercialization of medicine.

It is time to heed that wisdom. I submit that we will not be able to
have good quality, accessible health care at an affordable price until
we restore physicians as independent, ethical health care professionals,
and until we restore small, independent, community responsible,
non-profit hospitals as the locus for inpatient care.

"The North Carolina dental board and a group of dentists have filed lawsuits against DentalWorks, alleging that the dental chain pressured dentists and dental workers to give patients expensive, unnecessary treatments."

"In addition, DCP used internal recommendations, warnings of malpractice lawsuits, and other pressure to push dentists and hygienists to falsely diagnose patients with periodontal disease, the complaints allege."

I appreciate what you are doing, Dr. Silverstein. Patients deserve transparency. It's Hippocratic.

In 2009 I was diagnosed with colorectal cancer. I live in Houston so I went to the best non-profit research cancer hospital, MD Anderson, where I, along with other patients, was treated like cattle and my cancer treated like something that existed soly to give doctors something to experiment on. Radiation was very successful but it was done at a suburban branch of Anderson. Tumor reduced almost 80% but the surgeon refused to change the extent of what was being cut. After I requested a change of surgeon I was refused surgery and offered only chemo for a condition needing surgery. I tried 2 other cancer centers in Houston finding them both wanting. So, I went to CTCA where my transportation to the hospital was free, I was treated like a human being, didn't pay $12/day for parking, ate organic food in the cafeteria at only a few dollars a day, when an outpatient was able to live in the hospital building in a lovely motel room for $40/day. I have been home and healthy for several years but am having some new issues and I called Cancer Treatment Centers of America because I trust them to do what is right. Since the comments are moderated I will be surprised if this makes it to the web but addressing the author of this blog, naturopathic, chiropractic, etc. are legitimate parts of any successful treatment because we are not machines but humans whose wellfare is affected by state of mind, food consumption and mental state. You remind me of the docs at MDA, all about themselves and their science with little real care for the patients they treat.

I am sorry that you had to go through a difficult experience. I certainly understand how upsetting, unpleasant, painful, and frightening cancer treatment can be.

If you look through our blog, you will see that we have been as critical of leadership and governance of non-profit hospitals and health care systems as we have of for-profit ones. I also am perfectly willing to believe that individual patients may have bad experiences at big non-profit medical centers, and individual patients may have good experiences at for-profit hospitals.

That being said, I don't think the fact that you were treated more humanely at CTCA nullifies the concerns raised in my post above.

A few weeks after my mother passed away, CTCA mailed my mother a customer satisfaction survey! This was consistent with the way my mother and family were treated by doctors Crilley and Topolsky. When I called my mother’s team a few days before her death to let them know about her turn for the worse, they continued to fail to check in with the doctors managing her care at the hospital, or with her or the family, even after I clearly told them she was expected to die at any moment. After her death, many doctors outside of CTCA called or sent a sympathy card, but not a word from her CTCA doctors. Did they wonder what happened when their patent stopped showing up for appointments? Did they write her off as the hospital/hospice’s patient, thereby boosting their own mortality statistics? Are these accusations unfair – if so, I would love to hear the reason.

CTCA has customer service and “quality” teams highly dedicated to the mission; that is, if the mission is to put up a barrier and prevent doctors from having to deal with pesky relatives. Several members of these teams have told me “I’m sorry you feel that way,” the type of standard operating procedure that makes CTCA feel they are covering their bases legally but the type of apology that enrages families. A simple call or letter from a doctor could have provided closure and resolved this customer service complaint. The longer this continues to fester, the more likely it is to turn into a legal battle as we find ourselves questioning all treatment leading up to my mother’s unexpected death. How could CTCA give my mother optimistic test results and hope while at the same time the cancer had spread and her lungs were filling with fluid? It doesn’t make sense, even to my mother’s friends and medical advocates who sat in on her sessions.

I will say I have heard anecdotal rave reviews about other CTCAs, so I wouldn’t want to deter anyone from seeking treatment at the others. However if you are in desperate enough circumstances to seek out CTCA, ensure friends and relatives all have your password and permission to review your treatment, so CTCA cannot hide negligence behind patient privacy laws.

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